Trajectories of Health Care Contact Days for Patients With Stage IV Non–Small Cell Lung Cancer

Key Points Question What are the trajectories of contact days (days with health care contact outside the home) for patients with stage IV non–small cell lung cancer (NSCLC)? Findings In this cohort study including 5785 decedents with stage IV NSCLC, the median survival was 3.5 months and patients had spent 1 in 3 of those days with health care contact outside the home. Normalized trajectories followed a U-shaped distribution such that contact days were most frequent immediately after diagnosis and immediately before death, with a middle trough. Meaning The study findings suggest that patients' and their care partners' lives may be consumed by health care, and there is a need to benchmark appropriateness, better support patients and care partners, and improve care delivery.


Outcomes
Healthcare contact days were identified with any health administrative records for inpatient acute or rehabilitation hospitalizations (DAD, OMHRS, NRS); emergency department visits (NACRS); outpatient surgeries (SDS); cancer clinic visits (NACRS); dialysis clinic visits (NACRS); long-term or complex continuing care (CCRS); outpatient contact (e.g., family physician, imaging, injections/infusions, and radiotherapy assessment and treatments) (OHIP); and blood lab test visits (OLIS) from the selected ICES databases.Healthcare contact was counted once per day regardless of the duration, location or reason of contact.

Covariates
Socioeconomic status was based on community-specific or neighborhood household income quintiles.Rurality of residence was classified using the 2008 Rurality Index for Ontario (RIO), with higher scores representing a greater degree of rurality: Rural area (RIO score ≥40), suburban area (10≤ RIO score <40), and urban centers (RIO score <10) (1).Smoking status was based on survey respondents in the 2015-2017 Canadian Community Health Survey (CCHS) data; specifically, area-level age-sex standardized rates were computed with the 2016 Ontario census division (CD) geography and population to represent the areal smoking status (i.e., higher than average, typical average or lower than average) for their place of residence.Comorbidities were measured using the Elixhauser comorbidity index derived from hospital records from the DAD and SDS databases with a 5-year lookback from their NSCLC diagnosis (2).Chronic conditions (e.g., asthma, hypertension, and dementia) were based on the ICESderived databases.
Systemic therapy was described with specific anticancer medications from the ALR, NDFP and ODB databases, while radiotherapy was defined with specific treatment activities from the ALR database.OpenStreetMap data between the postal code of residence and the geographic location of the regional cancer center.

eFigure 1 :
Cohort creation of patients diagnosed with stage IV non-small cell lung cancer (NSCLC) from January 1, 2014, to December 31, 2017, in Ontario, Canada Ontario Cancer Registry of NSCLC diagnoses from January 1, 1964, to December 31, 2017 N=187,452 patients Linkage with other ICES data sources N=180,604 patients Exclusive primary NSCLC diagnoses N=136,633 patients Stage IV NSCLC diagnoses from January 1, 2014, to December 31, 2017 N=6,810 patients • Missing/invalid age or sex (1,233 patients) • NSCLC diagnoses on or after death (5,615 patients) • Other non-NSCLC diagnoses (43,704 patients) • Systemic therapy, radiotherapy, or metastasis surgery for unregistered cancer diagnoses (267 patients) • NSCLC diagnoses in 1964-2013 (119,080 patients) • Stage I-III, unstaged, or non-histologic NSCLC diagnoses in 2014-2017 (10,743 patients) Ontario decedents with eligible medical coverage N=5,785 patients • Surviving >2 years after NSCLC diagnoses (888 patients) • <20 years of age, out-of-province residency, or lapses in Ontario medical coverage (137 patients) Classification of systemic therapy administered for patients diagnosed with stage IV non-small cell lung cancer (NSCLC) from January 1, 2014, to December 31, 2017, in Ontario, Canada eTable 3: Descriptions of the ICES health administrative databases, outcomes and covariates CIHI, MOH It contains administrative (e.g., institution, and disposition), clinical (e.g., diagnoses, and procedures/interventions), and demographic (e.g., age, gender, and location of residence) information for all patient visits made to day surgery institutions.CIHI, MOH It contains administrative (e.g., institution, and disposition), clinical (e.g., diagnoses, and procedures/interventions), and demographic (e.g., age, gender, and location of residence) information for all patient visits made to hospital-and community-based ambulatory care centers (e.g., emergency departments, hemodialysis units, and cancer care clinics).CIHI, MOH It identifies Ontario adults aged ≥40 years with dementia based on an ICES-derived validated algorithm using the OHIP, DAD, SDS and ODB data.Acronyms: MOH, Ministry of Health; OH, Ontario Health; CIHI, Canadian Institute for Health Information; RAI-MDS, Resident Assessment Instrument Minimum Data Set; HSSO, Health Shared Services Ontario Descriptions were drawn from the ICES Intranet with adaption from the following references: 1. ICES.ICES data dictionary.https://datadictionary.ices.on.ca.Accessed January 10, 2023.2023.2. ICES Privacy & Legal Office.ICES Report to the Information and Privacy Commissioner of Ontario: Three-Year Review as a Prescribed Entity under PHIPA, 2020.
Metastasis surgeries were identified from cancer-related surgical interventions from the DAD database related to brain resection or spinal cord compression.Palliative systemic therapy, radiotherapy and metastasis surgery treatment were measured from NSCLC diagnosis to death.Overall survival and specific contact days for patients diagnosed with stage IV non-small cell lung cancer (NSCLC) from January 1, 2014, to December 31, 2017, in Ontario, Canada, stratified by type of systemic therapy Sociodemographic and clinical characteristics for patients diagnosed with stage IV non-small cell lung cancer (NSCLC) from January 1, 2014, to December 31, 2017, in Ontario, Canada, stratified by overall survival Driving distance and duration were measured with the shortest distance generated from the Open Source Routing Machine (OSRM) API with OpenStreetMap data between the postal code of residence and the geographic location of the regional cancer center.Sociodemographic and clinical characteristics, for patients diagnosed with stage IV non-small cell lung cancer (NSCLC) from January 1, 2014, to December 31, 2017, and receiving systemic therapy from January 1, 2014, to December 31, 2019, in Ontario, Canada, stratified by time to initiation of systemic therapy from cancer diagnosis Column percentages may not sum to 100% due to missing data.Small cell responses with ≤5 patients were suppressed.b.Chronic kidney disease (CKD) was measured with an average estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73m 2 from multiple laboratory tests within a 1-year lookback period from NSCLC diagnosis.c.ESAS assessments were measured within a 3-month lookback and lookforward periods from NSCLC diagnosis; ESAS symptoms were categorized as localized physical (pain, nausea and shortness of breath), generalized physical (tiredness, drowsiness, lack of appetite and wellbeing) and mood-based symptom clusters (anxiety and depression); maximum intensity scores from any ESAS symptom within the cluster were used when multiple assessments were reported.d.Driving distance and duration were measured with the shortest distance generated from the Open Source Routing Machine (OSRM) API with OpenStreetMap data between the postal code of residence and the geographic location of the regional cancer center.Overall survival and contact days for patients diagnosed with stage IV non-small cell lung cancer (NSCLC) from January 1, 2014, to December 31, 2017, in Ontario, Canada, stratified by overall survival and time from diagnosis to systemic therapy initiation Multivariable analyses for healthcare contact days in specific months for patients diagnosed with stage IV non-small cell lung cancer (NSCLC) from January 1, 2014, to December 31, 2017, and not receiving systemic therapy from January 1, 2014, to December 31, 2019, in Ontario, Canada ARR, adjusted relative risk; CI, confidence interval; RIO, Rurality Index for Ontario; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure; CKD, chronic kidney disease; ESAS, Edmonton Symptom Assessment System; km, kilometer Notes: a.Additional sociodemographic and clinical characteristics included (but not shown) in the multivariable analyses: Place of residence, smoking status, Elixhauser comorbidity index, histology/morphology, anatomical location, palliative radiotherapy, metastasis surgery, year of diagnosis, inpatient hospitalizations and emergency department (ED)-only visits.b.Chronic kidney disease (CKD) was measured with an average estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73m 2 from multiple laboratory tests within a 1-year lookback period from NSCLC diagnosis.c.ESAS assessments were measured within a 3-month lookback and lookforward periods from NSCLC diagnosis.d.Driving distance was measured with the shortest distance generated from the Open Source Routing Machine (OSRM) API with © 2024 Gupta A et al.JAMA Network Open.eTable 7: Acronyms: © 2024 Gupta A et al.JAMA Network Open.